Tag: doidge

Unlike a simple sense impression such as taste or smell, pain seems to be a fully-fledged, mind-body experience. We don’t just feel pain — we are gripped by it almost like an emotion or mood. How does that happen? Does pain always correlate with injury in the body? I’ll try and keep this short, and as jargon-free as possible!

Fancy a warm day at an idyllic beach. Wading towards the shore after a long leisurely swim, gazing around at the sunlight on the waves, you unexpectedly stub your toe on a submerged rock. Let’s use that example to analyze what’s going on as you suddenly find yourself dealing with a flurry of unpleasant feelings.

Nociception

I know, you’re like noci… wha?? Jargon straight up! Don’t stress — I never heard this word until a couple months ago either. But this is the only jargon for the whole article, ok? Bear with me …

Roughly speaking, nociception is the name for the pain signal before it reaches the brain. Interestingly enough, nociception itself does not cause much of a reaction in the area where the injury happens.

In the case of your accident at the beach, it is not until your brain receives a signal from the toe, that any kind of response begins to take place.

Nociception vs Pain

When we get a signal that “something hurts”, how does that expand into such a rich experience that all or most of our concentration and our emotions are suddenly turned towards it?

Well, as soon as your brain receives the nociception signal it does some trickery to figure out how bad the damage is (if you just scratched yourself or if you cut yourself deeply). It also looks into where the signal is coming from and how easily damaged that area tends to be (if you stub your toe it hurts more than if you hit your arm).

You’re already starting to feel things in a context that is more than just simple nociception. Next up perhaps memories will crop up of the last time you stubbed your toe, you’ll lift your foot out of the water and examine it closely. Your eyes and visual parts of your brain will be processing all those images. If you’re like me you’ll be wondering if anyone has noticed and if you perhaps look a trifle silly standing on one leg in the water with your other foot held up in front of you. You’ll be trying not to topple over.

Our mind has gone from soaking up the summery day, to a more active state. After the initial fast signals, the toe is now sending slow throbbing nociception signals to our brain, and every time a new throb reaches our brain, it goes through that whole activation state again. It returns our focus to our foot from whatever else might be going on. Now we are experiencing pain.

What’s interesting is that nociception and pain can be experienced separately. While normally of course, nociception does lead directly to an experience of pain, in some cases it is possible to experience great amounts of nociception but to be in an entirely pain-free state. This is sometimes noticed in cases of “massive trauma” [2] by paramedics in victims at the site of a car crash.

The opposite is also possible, for example when “individuals with functional pain syndromes report considerable anguish in spite of having [no measurable -nociceptive activity]”. [2]

Pain as a Perception

These understandings and many more led Ronald Melzack, a Canadian who studied phantom limbs and pain, to refer to pain as an “output of the central nervous system”. (Ok, a tad more jargon. “Central nervous system” is a medical term for the brain and spinal cord.)

What Melzack is saying here is that although pain does start starts in the site of injury, it is not until it is taken into the central nervous system and evaluated as being important enough to warrant attention, that the pain begins to intrude on our thoughts and emotions. This is more like a perception, where we are not just receiving sensory input but thinking about it and evaluating it.

Although this may seem quite obvious, you can see that rolling all of this together and calling it “pain” turns pain from being a simple realisation that “something hurts” to being the full mind-body response to an incident of nociception, and not just the nociception itself. Linking it all together like this is the only way to explain complex pain syndromes like those outlined above, or in the case of a phantom limb causing pain, where the pain persists in the brain long after the nociception has ceased.

The particular brain regions that are involved in taking up the call of pain, on behalf of the nociception from the site of injury, in order to generate this “output” are many. Moskowitz identifies no fewer than sixteen different brain regions! [3] and [4] Many of these are connected with our emotions and our thinking patterns, and others are connected with our body’s most basic self-monitoring and survival systems.

This explains why pain can be such a distressing experience, and why we sometimes shrink away even from the thought of hurting ourselves. The emotional centres of our brain are anticipating our potential distress and creating aversive reactions before the pain has even happened, by simulating the pain independently of receiving any actual nociception.

Conclusion

I’ve found this knowledge to be the start of a whole investigation into the nature of pain. Knowing that pain is partly to do with how I evaluate it, and not just a result of being told “something hurts” by my body, has been quite an eye-opener for me.

I hope you’ve found it interesting too. If so be sure to like my Facebook page or follow my blog for more updates. I write about wellbeing and mindfulness, with a few creative pieces thrown in from time to time.

Further Reading

Here are some useful links I’ve found while reading about pain theory.

Support groups are not really my thing. If I hadn’t kept a diary today, then I’d probably not have considered the idea of looking for one.

This morning Leo asked if I’m hurting a lot and I paused before replying to his question, but just to assemble my thoughts. I’d been visualising way more than yesterday — interrupting myself, or him, mid-sentence even, to close eyes and wrest some processing back from protesting brain regions, before jumping back into the flow of conversation, or finishing coffee extraction, or spreading my toast. But when he asked that, I was feeling pretty good.

“It’s funny. Today the pain is coming in waves, so there are these gaps where the pain stops. That means that I notice when it resurfaces and I’m like Oh! I can use this to practice some more. Yesterday, the pain was actually way worse but it was constant. I think I was visualising less. When there’s never a moment when you’re not getting a hot-knives feeling in three, five, ten body parts, you don’t get the cue to visualise. It just grinds on incessantly. I don’t want to just sit in a chair all day doing this, but it’s like, ‘Well, if I don’t do it all day, when, then?’ When the pain is constant, there’s no contour or trigger to visualise.

“I still don’t know what to do on these kinds of days.”

I wrote about this exchange in my diary after breakfast, and it has been echoing in my head all day.

If I’m to make a success of this practice then these flare-up episodes are the proving ground. If I don’t rewire the networks to the level where I can prevent all or most episodes, then it will have failed. I don’t want just another crutch like breathing techniques or restorative yoga. Wonderful as those practices may be, they do not unravel the wiring of chronic pain, they are basically just an alternative to pain medication — when stopped, the pain gradually returns. As the quote from Doidge I posted earlier says “unlike medication … the neuroplastic technique allows patients to reduce its use over time, once their networks have rewired.” [1]

Although I might be starting to find traction with the days in between the flare-ups, I still don’t have a handle on the flare-ups themselves. This realisation dawned on my gradually, almost reluctantly, over the course of the day, through writing and mulling it over in my head. Tonight as I type this entry up I have the problem staring me in the face again. So as I said at the start of this post, I’ve begun researching and tracking down a few pain forums online. One of them is even based out of NZ and may lead to me finding a local face-to-face group that I can refer to when stuck like this. More investigations to come.

This is a perfect illustration of why keeping a diary is so incredibly beneficial for me while making a lifestyle change like this. Thanks to those of you who are reading, and those of you who are not, well, up yours!

What Moskowitz has added to our understanding of this ability of the mind to eliminate a particular pain is that constant mental practice is necessary to strengthen this ability and change the firing of the brain in a way that is sustained. Unlike medication or placebo, the neuroplastic technique allows patients to reduce its use over time, once their networks have rewired.

The effects last. Moskowitz has patients who have kept their gains for five years. Many of his relatively pain-free patients still have damage in their bodies, which can, on occasion, trigger acute pain. He thinks that once they have learnt and practised the technique over hundreds of hours, their unconscious mind takes over the task of blocking pain by using competitive plasticity. When it doesn’t, they can still use the spike of pain as the signal to consciously use competitive plasticity to do more rewiring. “I don’t believe in pain management anymore,” says Moskowitz. “I believe in trying to cure persistent pain.”[1]

Why am I writing these updates? I don’t expect they’ll be relevant to many people (and that’s a good thing!). Maybe someone stores away the info for later and circumstances change and it becomes important for them — that’s one possibility. But mostly it’s just a way of keeping a diary; I’ve rarely been able to determinedly effect change in my life without one. And I’m aware this time that a) the stakes are high and b) the level of moment by moment commitment required to make this work is unprecedented. So diarying out in public makes sense to me — it’s as though I’m accountable. Not to anyone in particular. It’s just a social hack to eke every bit of determination I can get out of the situation.

Same reason people go on silent retreats in groups. Gathering together to be silent. Not for the idle banter that’s for sure! But because socially we get an extra ounce of energy from doing things together. Which illustrates another reason, really. It’d be just too damn lonely doing it on my own.

What’s so special about visualisation? There are many things that we can focus our minds on instead of pain. Listen to music. Daydream. Do exercise. Develop software. Play. Go for a walk. Have coffee dates. Go to parties. Travel. Trust me, I’ve tried all of the above and more. The list of things is as long as our society’s bewilderingly long list of entertainments. It even goes beyond entertainment: meditation (focus on breathing), yoga, psychotherapy. Then there’s painkillers, ice-packs, massage… Why choose to visualise, out of all these possibilities? How is it any different?

On some level, it’s not different at all. All these things — visualisation included — remove the pain from our consciousness. The difference is, that most items from the above list don’t stop the pain programme from running subconsciously. They push the pain out of our awareness, but that just means the pain signals are received and processed in our brains on autopilot, while our backs are turned if you like. They run unopposed. It is in this exact environment that the pain maps are enlarged through “neuroplasticity gone bad”, until they are running at up to five times the level of sensitivity than is usual for non-persistent “acute” pain.

Visualisation is different because in order to visualise at all, we must engage the very brain regions that are hyper-involved — fivefold — in persistent pain processing. We are not distracting ourselves or ignoring the pain. We are challenging it directly.

Say you have an over-eager puppy at the park. Your puppy is running up to kids and jumping at their face, eating their sandwiches, crapping in front of their mums (bear with me here). She’s generally just acting as she pleases.

You have several choices on how to improve things. You could scold her and tell her how bad she is, give her a smack every time she nears another person. That will get her behaving, but she’ll be scared of you, scared of other people, and eventually the relationship you have with this puppy won’t contain the love and companionship you’re both aiming for. You could take her home and never to the park again, but that would have a similar effect.

You could also take her running around and around the park, to all the trees and the river and back to the playground and around the park again, distracting her until she’s so exhausted that the idea of eating a kid’s sandwich never even enters her mind. Good luck with that. Most puppies have more energy and can run much longer than you can. And as this puppy matures, all you’re going to get is one very fit and healthy animal that can outrun you all day and still jumps up at children, still eats their sandwiches and craps on their picnic blankets (sometimes it might even mix those actions up a little!)

Another option is to put your puppy on a leash, and train it up with little doggy-snacks to come when it’s called, so that eventually you can drop the leash.

In our analogy, the pain is the puppy. Maybe you’ve tried scolding yourself to get rid of the pain, or maybe you haven’t. Chances are though, if you’re in persistent pain, then you’ve tried the distraction tactic — giving your mind so much to focus on that it “can’t” process the pain. Now you’ve got a very strong, fit and healthy network of neurons that you’ve unwittingly trained to outrun and outpace every distraction you throw at it.

Time to get serious and take those neurons to puppy school! Continuing our analogy, the visualisation is the leash. By visualising, we give those neurons something else to do instead of pain processing, just like with the leash we can guide the puppy to stay on the path. When the puppy is on a leash, she can’t run quite so riot. We are not distracting her temporarily, nor punishing. We are training her to do a different job.

Training means being relentless. We train our neural architecture just like the puppy. We even have temporary pain relief that functions like a little snack as an incentive.

Of course, at times puppy will still get ideas about eating duck poo or chasing cats. But because you have not just indulged her with temporary distractions, because you have invested time in teaching her a different job, you can call on that training. Call her back to neutral. And she will stray less and less. Eventually you won’t even need a leash or the snacks.

I never sleep well on a full moon. Energy levels are an ally in this neuroplastic technique, when they’re high; a huge hurdle when they’re not. Unless you’ve lived with pain for years, it’s hard to appreciate that your fellow humans won’t have deep reserves of endurance to draw on in these situations. Already worn thing by putting up with pain for a number of years — a kind of emotional and metabolic “death by a thousand cuts” — on top of that the neuroplastic technique itself saps energy. The temporary relief one may gain does give a temporary boost at times, but in general we are intensively rewiring a large multiplicity of neurons here, in regions all across the brain.

It is well established that in periods of high usage the brain can be responsible for up to twenty percent of ATP (cellular energy) drain in the body [1]. That’s a huge amount for something so small!

(OK, some of us have bigger brains than others [2]).

Regardless of one’s individual brain size, one can expect to feel drained when undertaking this kind of relentless brain training. I’ve personally made a deliberate effort to increase calories and essential brain nutrients like tryptophan and carnitine through nourishing foods (plenty of that!) and supplements. It’s also worth investing in a quality form of CoQ10 that can help boost production of ATP throughout your body including your brain (plus there are anti-ageing benefits to such a high-strength antioxidant that anyone can appreciate).

When choosing a CoQ10 supplement, avoid the standard off-the-shelf pharmacy brands — they’re not worth throwing your money at. You will literally excrete them unchanged. You want it in ubiquinol form, a bit more pricey but at least it is bioavailable to your system [4]. Or if you’re feeling particularly Bank, the MitoQ developed at Dunedin University is “mitochondrially targetted”, meaning that 850 times the CoQ10 actually reaches your mitochondria where it’s needed for ATP production. I have taken a bottle dose of their standard supplement for the last month. I noticed a subtle but significant feeling of energy and endurance that I’d not had for a long time within five days of taking it. I kept taking it for a month before talking about it, afraid that the effects would wane. But they haven’t. I now credit MitoQ with stabilising a downward spiral of fatigue and making it even conceivable for me to begin the neuroplastic training regimen. My second bottle just arrived and well worth the $85 per month that it’s costing me [3].

(BTW I’m not getting any kickbacks for suggesting these things, just sharing what I’ve tried that works for me!)

Back to the full moon. That plus the collision of several worlds ended with me not getting even two hours sleep last night, plus currently at a stalemate vs the seasonal headcold and you could say I’m not a big dynamo of energy right now. I’m having a corresponding setback in pain today. Rather than individual pain spikes that I can neatly nip in the bud with a bit of visualising, I’m getting these non-distinct waves of pain. They change location but I couldn’t really say there has been a time at all today where the pain wasn’t intruding on consciousness. The technique which has been giving me no little amount of relief for the past week is in disarray. I struggle with focus when sleep deprived (I’m sure you do too!).

I’m not really doing anything today. Concentration is low enough that it’s not an option to visualise with closed eyes like yesterday, so I’ll feel pain and be forced to stop a task only to become distracted and lurch back into activity before realising that the visualisation wasn’t complete, at which point I’ll stop again and try finish what I was doing. As I noted back on day 11, the level of pain itself has an inversely proportional relationship to concentration levels, which is not exactly helping the situation today.

I know this will change though. I know it’ll get better. I’m just in a trough between two breaking waves. Many more will come, just as the glimpses of freedom, the vista and freshness at each crest, also come and go, only to come again. It would be so easy to give up now. A relief, to turn and run. But the relief is a trap — there’s nowhere to run except pain. So again, I find myself falling back on the Litany against Fear:

“I must not fear. Fear is the mind-killer. Fear is the little-death that brings total obliteration. I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain.”

When the fear has gone there will be nothing. These troughs, they resolve like a line drawn in water. Utterly ephemeral. But what we do during them, just like plowing the soil in winter, cultivates our habits for the coming thaw.

So it’s Day 15 of this “pain map visualisation” trial. I’ve been practising to shrink those virtual maps in my minds eye but keeping my actual eyes open. I’m now able to do that more often than not. Visualising with your eyes open might sound weird, but it’s something we do all the time without thinking — e.g., when we review our upcoming route while driving. What makes it possible is familiarity — of the route and the act of driving, or in this case, of the visualisation and whatever task I might be performing.

A big advantage of this is that the practice can become more integrated in daily life. The visualisations can be more long-running. Instead of dropping everything to bring the images to mind, I can have them playing back throughout the day, although I do of course drop them and focus when necessary, e.g., when speaking about something complex.

In general, it’s helping to make things more integrated, so the practice is finally becoming a bit less intrusive on my daily life. But I still stop mid-walk periodically, in response to a pain spike and appearing struck dumb to an outside observer I suppose, while I run through the visuals. And I still struggle with mornings. The imagery is a lot more vague and broken up when I first waken. I’m evolving the visualisation each day as well, to keep the interest level high. For both those reasons, I continue to sit quietly with eyes closed each morning, thus evolving the animation and also overcoming the morning struggle early on.

When I first started practising there wasn’t much detail or sophistication to the visualisation — just three or four red blobs in random locations, getting smaller. That was enough though. But over a few days I started to include a particular sense of whereabouts in my skull they were located (interestingly, I’ve since discovered upon receiving Moskowitz’s book[1] that two of those locations were bang smack in the middle of the two most active regions highlighted).

Soon after that, I added different colours — red fading through orange to yellow, green, blue, the whole spectrum to black and just empty, quiet, blessedly pain-free space inside my head. These were inspired by MRI images but not trying to hold true to any scientific accuracy. Unexpectedly it seems that the more movement and shifting I put into the shapes the more powerful the temporary relief is. I guess because it requires more engagement from the relevant systems.

Last few days I’ve begun to experiment with each region being a three-dimensional structure, red in the centre, surrounded by orange, yellow, green, blue corona. As each central blob shrinks, it drags the other colours with it until the whole thing shrinks to a violet shimmer and eventually fades or stutters out. and all I’m left with is a baseline of little colour sparks surrounded by quiet, calm blackness.

This is what works for me. Changing the visualisation a bit each day makes it harder to run the visualisation while doing other things, because I lose familiarity with each change. But it’s more fun to keep it challenging.

The Moskowitz book has dozens of examples of imagery that has worked for others, and it’s clear that there’s no need to try and reproduce anything in particular. As long as it’s engaging enough to focus the mind and keep it from running the pain programme unopposed, then it’s good enough.

Today I have done more visualising than ever because I have a head cold. That means I have persistent aches from the virus on top of the persistent aches from the pain syndrome. (I’m resisting saying that the latter aches are caused by whiplash injury. While that may have been the case originally, it’s now morphed — literally — into a disease all of its own, known as “chronic pain” or “neuropathic pain” or as Moskowitz calls it, “persistent pain”).

I’m right tired now, so will make this entry short.

While it was an interesting exercise to try and sort out the different pain spikes into “virus related” or “needs visualisation”, eventually I realised that the virus-related pain presented just as much of an opportunity to practice as did the pain syndrome symptoms. So what that’s ultimately meant is that today I’ve done visualising for virus-related pain as well, which has meant that I’ve done more visualising than ever.

Nearly two weeks ago I began practising a form of “neuroplastic brain training” designed for people suffering persistent pain. This was in an attempt to resolve neck, head and at times whole-body pain that I’ve been experiencing since being hit from behind by a bus while driving in 2012 (there were two subsequent cases of whiplash and a concussion after that, which have likely contributed to the pain getting worse and not better).

Today I’ll try and explain how I practice the technique every day. Hopefully you’ll see that, despite the seemingly complex theory behind it all, the visualisation is actually quite simple, and even rather beautiful if you use the suggestions in here. There is also plenty of freedom to engage your own creativity when coming up with your own visualisation — in fact, that’s encouraged!

When I first started this technique thirteen days ago I didn’t have a lot of material about it. I had read of the benefits and some pretty useful discussions about attitude in Doidge’s book [2]. But there were no actual images of what to be picturing in my mind. Instead, for visual specifics, all I really had to go on was a single paragraph:

“[Moskowitz] visualised the very brain maps he had drawn, to remind himself that the brain can really change, so he’d stay motivated. First he would vbisualise his picture of the brain in chronic pain — and observed how much the map in chronic pain had expanded neuroplastically. Then he would imagine the areas shrinking, so that they looked like the brain when there was no pain.” [4]

Not willingly idle while awaiting Moskowitz’s book from Amazon USA, I went ahead anyway and did it kiwi style, as the first ever entry in this Chronic Pain diary explains. [1]

I figured, “well, I’ve seen pictures of fMRI scans online. I’ll just Google some of those and play around with them visually.”

I knew from Norman Doidge’s book [2] that it doesn’t matter at all what you visualise. The whole point is, that by visualising anything — anything at all — we engage brain regions that are involved in both pain processing and visual imagination. By bigging up the visual imagery, we dampen down the pain, goes the logic. Eventually, through thought stimulation, we rebuild the anatomy in those regions (hello, neuroplasticity) to focus less on pain. Eventually, we can leave out the visualising altogether and go on about our lives, only occasionally making recourse to the technique whenever pain spikes recur (but that apparently becomes a rare event — bring that shit on).

So far, nearly two weeks in, I’ve found all the information I could have needed in Doidge’s book, by reading the relevant chapter a few times and relying on my own imagination when coming up with the visual images. Moskowitz’s book is definitely worth having too, and although pricey, you can’t fault the shipping which had it to my door from the US within a week!

Moskowitz, the creator of the technique, suggests to visualise brain maps shrinking, because it probably helps with motivation to relate it directly to the intended goal, but if I was feeling facetious I’d suggest it’s also because he’s spent a lot of time looking at such things in his professional life. From what I understand you could just as well be visualising Tibetan deities (an interesting thought, considering how important that practice is within the Tibetan tradition). There could well be advantages to coming up with your own imagery, as this will engage more regions of your brainware than just memorising the images that Moskowitz uses.

Having said that, I went with the “brain maps” idea, and I’ve found it solid.

Whenever a pain spike intrudes on consciousness, I gotta say my first instinct is to ignore it, and hope it’ll go away. Next tactic is, to rearrange my body — to “twitch” it into a shape where the pain is lessened. I’m a slow learner.

Eventually, I remember that I’m doing that other thing now, that visualisation stuff. I don’t have to live with this persistent pain shit any longer. For real! OK, wake up from distraction.

Feel the pain. Recognise it. And then I do my best to get motivated by remembering that the pain isn’t actually in my neck — not really. Pain is only experienced when neural signals are interpreted at “the thinking parts of [my] brain” [5]. I remember that once acute pain develops into persistent pain, the number of neurons dedicated to processing it increase five-fold [6].

Set the Intention: to return the brain to its original pain processing configuration, freeing up those neurons to do other jobs, and freeing my mind from the constant bracing against discomfort.

After all that talk, the visualisation is actually a simple three-step process:

Establish mentally that the location of pain is actually inside my head, not in my body.

Visualise the pain as glowing “starburst” regions — it doesn’t, in fact, matter at all where one puts them or how they’re shaped. I find that there are certain locations in my imaginary skull cavity that my mind naturally puts them, so I just go with it.

Shrink them, using whatever imagery comes to mind — but I make it quite a long animation. Not just two frames, I shrink them progressively. I think about colour, and I change the colour of the regions as they shrink, cycling through all the rainbow (remember Roy G. Biv?).

Using Moskowitz’s “pain maps” suggestion a) helps remind me that the pain only exists if I allow my brain to reinforce those neural pain pathways. But b) it’s also my understanding that associating the visualisation with a particular location in my body engages the “posterior parietal lobe”, which, as well as being a pain-processing region, can be targeted neuroplastically by generating an “internal location of stimuli” [5].

I continually remind myself to visualise the shapes inside my actual skull where it is sitting now, not in some imaginary simulation of my skull out in front of or beside my actual body.

And that’s it! I repeat three times for strong pain, or until the pain diminishes, whatever is sooner. Whenever I feel pain.

It takes patience to interrupt what I’m doing and visualise, especially when I’m pressed for time. That’s probably the most challenging (and crucially important) aspect of the whole technique. R for Relentlessness.

But other than that, the visualisation itself is rather simple and even quite pretty, if you go for the colourful approach.

[1] Here in NZ, there is a bit of mythology around “making do” without necessarily having access to all the latest tools or materials. Number 8 wire and some tape will repair most things. That kind of thing. http://zigzagyogi.com/2016/07/visualization-for-chronic-pain/
[2] Doidge, Norman. The Brain’s Way of Healing, Penguin Books. www.normandoidge.com/?page_id=1042
[3] ibid. pp19
[4] ibid. pp15
[5] ibid. pp14
[6] Moskowitz, Michael, MD. Neuroplastic Transformation Workbook pp4, https://www.amazon.com/Neuroplastic-Transformation-Workbook-Michael-Moskowitz/dp/0615814654
[7] ibid. pp10